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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> iiiIIII;mmmlm - -- 1111111p 11112 <br /> This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> a enc:y regulatin the USTs within 30 days of the date of the monitoring system certification. <br /> 1. FACILITY INFORMATION <br /> CERS ID E5/13/19 <br /> Eftilding <br /> em Certification <br /> 10180861 <br /> Business Name (Same as Facility Name or DBA-Doin Business As <br /> 9 ) <br /> NuStar Energy <br /> Business Site Address City ZIP Code <br /> 3505 Navy Dr. Stockton 95206 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> ENameof <br /> any Performing the Certification hone # <br /> n Systems rp <br /> 408 ) 971 -2445 <br /> s <br /> e . San Jose, Ca 95112 <br /> Service Technician Performing the Certification (Print as shown on the ICC Certifrcation) <br /> Kristopher Bell <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/2020 <br /> Monitorin S stem Trainin and Certifications (List all a Itcable certifications. Expiration Date <br /> Incon 6/1 /2019 <br /> III. RESULTS OF TESTING i SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> Z Monitoring System Set-up Alarm History Report Y N NA <br /> Was any monitoring equipment replaced? <br /> (if "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? ❑ <br /> (If "Yes, " describe what was found in section IV below) ® El <br /> Is all monitoring equipment operational per manufacturer's specifications ? El El <br /> No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> EC <br /> � a <br /> g , <br /> <y <br /> NVIROtVIV ENT' L HL1zA1.TH <br /> DEPARTMENT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations , Title 23, Division 3, Chapter 16 , Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information (e.g . $ manufacturers' checklists, monitoring system set-up, alarm history report, etc. ) necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature +� 4_ <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = NotApplicable <br />